A history of the deadliest epidemics and largest quarantines in the world

Map of the COVID-19 global outbreak, as of 04/04/20. Image credit: By Raphaël Dunant - Own work, data from 2019–20 coronavirus pandemic data and List of countries and dependencies by population, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=88208245

In what is the biggest public health catastrophe to hit the world in modern times, the COVID-19 virus has been spreading rapidly - worldwide figures have crossed the 1 million mark with close to 60,000 deaths. A majority of the world’s population is under some restriction and India has imposed the world’s largest lockdown with its 1.3 billion people quarantined in their homes since March 26th, 2020.

Though the 2020 quarantine is unprecedented in its sheer numbers, the practice of quarantining is a rather ancient one and has been used since ages as a means of controlling epidemics. It was followed during Biblical times, and the Old Testament Book of Leviticus speaks of leprosy as being the first disease where people were isolated. The early understanding that leprosy was a contagious disease led to patients being kept in separate colonies. People afflicted with the disease had to yell out ‘unclean’, ‘unclean’ to announce their presence.

The plague, lazarettos and leper houses

The term ‘quarantine’, which means to isolate people or animals who may have come in contact with contagious diseases, originated in the Middle Ages when the city of Venice kept ships arriving in the port for 40 days before landing, to curb the spread of the plague. It comes from the Italian word quaranta giorni, meaning 40 days.

The quarantine followed the trentino, or 30-day isolation period, which had first been imposed in Dubrovnik, Croatia. This was at a time when maritime trade was booming, and many infectious diseases such as leprosy and the plague spread across Europe with the movement of the travellers. In 1377, the port city of Dubrovnik decried that anyone visiting its port would have to spend 30 days at a location outside the city to ensure that symptoms did not appear. The Bubonic plague, which spread across the world, killing 20 million in Europe was said to have a 37-day period between infection and death.

In 1423, Venice set up the first Lazaretto, or isolation station on an island near the city where people who were quarantined were isolated. This became a model for other countries, which set up Lazarettos to contain the spread of the Plague and other infectious diseases. In most cases, these lazarettos were located in areas that were away from the city and away from humanity.

Leper houses, where people affected by leprosy were sent to live in, also became widespread across Europe and India during the Middle Ages. Some of these colonies were located high up in the mountains to ensure that they were well away from humanity, while others were located on main roads so that donations could be raised. One of the last leper colonies were established on the Greek island of Spinalonga, in the Gulf of Mirabello in 1903, it functioned till 1957. India also has a number of leprosy colonies, with the one in Tahirpur, in the outskirts of Delhi as the largest.

The Yellow fever and the Spanish Flu

The Philadelphia Lazaretto was the first quarantine facility built in the United States. Image credit: Kiriakos Gogopoulos / CC BY (https://creativecommons.org/licenses/by/3.0)

While the first outbreak of yellow fever happened in the United States in the late 1690s, it resurfaced in 1793 when people fleeing a yellow fever outbreak in the Caribbean reached Philadelphia. The disease spread fast and between August 1 and November 9, 1793, nearly 5,000 people were listed in the registry of deaths - 10 per cent of the city’s 50,000 strong populations. Major port cities such as Baltimore and New York placed quarantines against people and goods coming from Philadelphia.

Many people were housed at the old Lazaretto which had been erected in 1743 to house patients. However, as more people fell ill, the original Lazaretto proved insufficient. A new Lazaretto was built in 1799 on a 10-acre plot, 10 miles south of the city’s borders. The Philadelphia Lazaretto could house up to 500 patients at one time and had beautifully designed buildings.

The quarantine, however, was not effective as the yellow fever was caused by a mosquito and the disease vanished as the mosquitos that caused the illness died once winter started in November.

The Spanish Flu, which killed 50 million people across the world and considered to be one of the worst pandemics in history, lasted from January 1918 to December 1920. The influenza was caused by an H1N1 virus and infected nearly 500 million people.

While the rest of Europe such as Germany, France and the United Kingdom tried to play down the casualties of the flu, the Spanish papers reported it extensively, hence, giving the impression that the country was the hardest hit. To counter the spread of the flu, a number of countries implemented various forms of isolation and quarantine, while schools were closed and a ban was implemented on large public gatherings.

The flu entered India via Bombay, reportedly brought by troops who were returning from Europe during World War 1. It spread across the country, disrupting lives and livelihoods and killed between 10-20 million people, making India the worst affected country. As there was no vaccine to protect against the influenza infection or antibiotics to cure it, the British Government tried to control the spread through quarantines and by recommending hygiene and self-isolation.

Modern quarantines

Nigerian doctors training on PPE by WHO during the Ebola breakout Image credit: By CDC Global - PPE Training, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=36016390

In November 2002, China suffered an outbreak of SARS after the first case of atypical pneumonia was recorded in the Guangdong province in China. The SARS virus spread rapidly, inflicting 5,300 people and killing 349 in China, crossing borders into Vietnam, Hong Kong and Singapore, and from there moving onward. Around 8,096 people were affected globally, while 774 people died. China and the rest of the world followed containment practises such as infection control in hospitals and other facilities, contact management, temperature screening, mask use, the monitoring of travellers and isolation and quarantine. Through these measures, governments were able to contain the spread of SARS by July 2003.

One of the deadliest outbreaks in terms of fatality was the 2014-16 Ebola outbreak in Western Africa, which had an estimated fatality ratio of between 25 and 90 per cent. The largest outbreak of the virus happened in Guinea, Liberia and Sierra Leone in Western Africa, where 29,000 people were affected and more 11,000 died. Over the course of the epidemic, it spread to Senegal, Italy, Mali, Spain, the United States and the United Kingdom.

While authorities in Guinea, Sierra Leone and Liberia announced the enforcement of mass quarantines and travel restrictions, at least 18 states in the US placed three-week-long quarantines on people returning from West Africa.

The quarantines were highly controversial. Lawsuits were filed in New Jersey and Connecticut pursuant quarantines being imposed on returning health-care workers. One of the lawsuits against the Governor in New Jersey led to the drafting of a new rule which said that quarantine after exposure to the Ebola virus would only happen if medically necessary. In a statement, the organisation Doctors Without Borders had said, "It has been our experience that lockdowns and quarantines do not help control Ebola, as they end up driving people underground and jeopardizing the trust between people and health providers.”